The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?
Left Side
Right Side
Directly in front
Where the patient wants
The Correct Answer is B
A. Placing items on the left side would not be appropriate for a patient with a right-sided weakness (hemiparesis) due to a left-sided ischemic stroke. This would make it harder for the patient to reach the items.
B. Placing items on the right side of the patient is the best option. Since the patient has weakness on the right side, they would have better access to items placed on the unaffected side (left side of the body).
C. Placing items directly in front of the patient could be helpful, but it depends on the severity of the stroke and the patient's ability to move and reach forward. It may not be as effective if the patient has limited mobility.
D. Placing items where the patient wants is a good practice, but the nurse should ensure the placement is practical for the patient's abilities. It is more important to place items on the right side to optimize access.
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Related Questions
Correct Answer is D
Explanation
A. Neutropenic precautions are used for clients with compromised immune systems, such as those undergoing chemotherapy or bone marrow suppression. This is not appropriate for bacterial meningitis.
B. Contact isolation is used for infections that are transmitted through direct contact with the patient or their environment, such as MRSA or C. difficile. Bacterial meningitis, however, is spread through respiratory droplets.
C. Universal precautions refer to standard infection control practices (like hand hygiene and wearing gloves) that apply to all patients, but specific precautions are needed for certain infections like bacterial meningitis.
D. Droplet isolation is necessary for bacterial meningitis, as it is transmitted via respiratory droplets from coughing, sneezing, or talking. This isolation prevents the spread of the infection to others in close proximity.
Correct Answer is B
Explanation
A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.
B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.
C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.
D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.
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